Current Practice in Tendon Management

Transcription

1 Current Practice in Tendon Management Handout Click on Therapy Flexor Tendons Denver Nancy M. Cannon, OTR, CHT Director Hand to Shoulder Therapy Center Indianapolis, Indiana Handouts talk & patient handouts Topics Indiana Early Motion Program Rationale for the place & hold exercise Case Examples Indiana Early Motion Program Initiated 25 Years Ago Modified Duran (PROM) + Place & Hold (AROM) Candidates for the Program Surgical Procedure 4 strand repair (profundus) Select Patients Understand & will adhere to the program & the precautions [surgeon/therapist clinical judgment] Postoperatively Digits passively supple Limited edema (7mm or less than digit opposite hand) Modified Duran Program Initiated Days Postop Edema begins to plateau Work of flexion & gliding resistance begin to [Manske, Amadio, Tang ] 2-3 Days Later Add Place & Hold Exercise

2 Place & Hold Exercise 1 st Stage Passive digital flexion combined with passive & active wrist extension 2 nd Stage Active hold Place & Hold Exercise Place & Hold Exercise 3 rd Stage Dropping the wrist into flexion Rationale Place & Hold Exercise Resistance - Profundus Place & Hold Exercise Extensive Research (over 25 years ago) Literature Lab Clinical Studies Patients Stronger Repair 4 strand + peripheral running suture (+ 47N) Therapy Program Prioritized addressing all factors WOF minimize resistance on the profundus Synergistic place & active hold exercise ( 10N) Active Flexion Evans & Thompson [JHT 1993] Short arc motion = 3N (FDP) Full arc motion = 9N (FDP) Greenwald et.al [JHS 1994] Light fist (active extension/flexion) 4N 9N (FDP)

3 Place & Hold Exercise Edsfeldt, Kursa et.al [JHS European Sept. 2015] Patients with CTR Factors Work of Flexion (WOF) Pulleys Edema Extrinsic Extensors Joint Stiffness Light fist 6.5N (FDP) Place & hold 3.6N (FDP) Force with repair & factors WOF Indiana Program Factors Favorably WOF Edema Bulky not removed until days postop Joint Stiffness PROM program precedes AROM by 2 3 days Combined program passive before active Extrinsic Extensors Wrist extended with active flexion Tendon Resistance through the Pulleys Venting the pulleys &/or excision slip of FDS Active Flexion Stay in the Safe Zone 4 Strand Repair 40N Calculation (N) Flexion Place & Hold Exercise 3.6N (FDP) Repair + 1.1N Edema 1cm + 1.8N 30% to 50% [PROM] -.6N Joint Stiffness --- Extrinsic Extensors --- Estimated Total 5.9N Calculation (N) Repair ADD Repair Type strand Peripheral Repair (minimum) SUBTRACT Initial Tendon Softening 10%-20% Repair Strength 30% 2mm Gapping Net: 40N 7N 47N - 8N - 12N 27N

4 Know the Repair Strength 2 Strand 20N 14N 4 Strand 40N 28N 6 Strand 60N 42N Button 45N Anchor Micro 70N Anchor Mini 45N Simple Peripheral Running Suture 7N 3-0 vs 4-0 Suture 10N 15N Case Examples Clinical Experience FDP (6 strand) repair Zone II FDP repair micro anchors Zone I FDS/P (4 strand) repair Zone II FDS/P (6 strand) repair Zone II FDS/P repairs (6 strand) middle and ring Zone II Case Example [A.F.] 13 y/o Girl; Fell & Cut Finger on Glass Table DOI: 6/15/15 Left Middle Finger Profundus Laceration thru A3 pulley [zone II] Surgery [9 days post injury] Six strand repair 3-0 Supramid suture Peripheral epitendinous repair Therapy [5 days post surgery] Indiana Early Motion Program Determine the Repair Strength 6 Strand 3-0 Supramid Suture Peripheral Epitendinous Repair 60N 10-15N 7N + 77 N* Does not account for: Factors that the work of flexion (WOF) Initial tendon softening 20% (max) Potential gapping at the repair site 30% (max) Therapy 5 Days Postop 7 Days Postop Dorsal Blocking PROM Tenodesis Place & Hold Weeks 1 3 Limited Participation in Therapy Initially ROM: 1 st Wk 2 nd Wk 3 rd Wk MP x/75 x/75 x/80 PIP x/95 x/95 x/95 DIP x/35 x/30 x/30 FLAT LINED

5 CPR Resuscitate Tendon Gliding! Change the Therapy Program! Give her a Chance Tendon Pull Through! Treatment Program Modifications Advanced Therapy Program by a Week Out of orthoses active motion at 3 weeks Added blocking orthoses exercise at 5 weeks Discontinued dorsal blocking orthosis at 5 weeks Began resistance at 6 weeks Foam piece (cylinder shape) Putty Hand exerciser Out of Orthoses Set Goals Active Flexion Markings in the palm Blocking Orthoses - Exercise Buddy Tapes 4 weeks postop Hand Based MPJ Block 5 weeks postop Blocking Orthosis 6 Weeks Postop Oval 8 All day Oval 8 Orthosis Wore throughout the Day

6 7 Weeks Postop Increase Tendon Gliding Putty & hand exerciser Outcome 11 Weeks Postop ROM - Left Middle Finger MP 0/90 PIP 0/110 DIP 0/55 [65] blocked motion Discharge Visit 3 Months ROM Left Middle Finger Case Example [J.S.] 22 y/o Male; Cut Hand with Knife at Work Right Middle Finger FDP Zone I & RDN Surgery [4 days post injury] FDP advancement micro anchors [70N] RDN repair Therapy Indiana Early Motion Program Therapy 6 Days Postop 9 Days Postop Dorsal Blocking PROM Tenodesis Place & Hold Wound Closure Persistent drainage Primary Challenge

7 Treatment Program Modifications MP Joint Blocking Orthosis [6wks] MP: 0/95 PIP: 5(0)/110 DIP: 10(5)/60 Outcome 3 Months Ultrasound [7 wks] Proximal phalanx Safety Pin Splint [8 wks] 3-4 times a day 30 min. Right Middle Finger Outcome Patient Video ASSH Annual Meeting 2015 Indiana Early Motion Program FDP Advancement with Suture Anchors Case Example [K.W.] 15 y/o Female; Cut Hand with a Knife DOI: 5/10/15 Lacerated Left Index Finger FDS/FDP & RDN Zone II Surgery [8 days later] Repair FDS/FDP & RDN Profundus repair: 4 strand + peripheral epitendinous repair [47N] Therapy 4 Visits 1st month of therapy Preferred minimal medical intervention Home Program Patient handouts Phone calls Text messages

8 Treatment Program Modifications 5 Weeks Postop Discontinued DBO; transitioned to buddy tapes Passive PIPJ extension with the MP flexed Outcome 8 Weeks Postop Pictures Texted! 20 4 Strand + Epitendinous Repair Current Outcome 4 Months Postop Outcomes Early Active Program Trumble et.al. JBJS 2010 Modified Duran/Place & Hold Program 54 Patients 6 weeks po 1 year postop TAM: PIPJ & DIPJ = Rupture rate: 3.8% Program Changes Gradually Eliminating Tenodesis Orthosis [Zone I & II Repairs] Partial repairs, buttons, anchors Easier to perform modified synergistic exercise 6-Strand Repairs Moving ahead of 4-strand repair program by one week (frequently) Out of the DBO 5 weeks po Modified Synergistic Exercise Amadio 1.7 N tension on the repair & passive glide - FDP Differential tendon gliding Allows distal glide of the profundus

9 Early Motion Programs Have Fun Treating Flexor Tendons! Essential to Know the Repair Strength Establish optimal treatment program Comfortable Imparting the Necessary Passive & Active Motion Prioritize Addressing Factors Impact WOF Adjust Program Limited Tendon Gliding Enjoy Denver Enjoy the Meeting!